Paul M. Fleiss, MD

Paul M. Fleiss, MD, MPH, is assistant clinical professor
of pediatrics at the University of Southern California Medical Center.
He is the author of numerous scientific articles published in leading
national and international medical journals.

Published in Mothering: The Magazine of Natural Family
Living, Winter 1997, pp. 36--45.

"Routine circumcision of babies in the
United States did not begin until the Cold War era. Circumcision is almost
unheard of in Europe, Southern America, and non-Muslim Asia. In fact,
only 10 to 15 percent of men throughout the world are circumcised."

"The natural penis requires no special care. A child's foreskin, like
his eyelids, is self-cleansing. Forcibly retracting a baby's foreskin
can lead to irritation and infection. The best way to care for a child's
intact penis is to leave it alone."

The Foreskin Is Necessary

By Paul M. Fleiss, MD, MPH

Western countries have
no tradition of circumcision. In antiquity, the expansion of the Greek
and Roman Empires brought Westerners into contact with the peoples
of the Middle East, some of whom marked their children with circumcision
and other sexual mutilations. To protect these children, the Greeks
and Romans passed laws forbidding circumcision.1
Over the centuries, the Catholic Church has passed many similar laws.2,3
The traditional Western response to circumcision has been revulsion
and indignation.

Circumcision started
in America during the masturbation hysteria of the Victorian Era,
when a few American doctors circumcised boys to punish them for masturbating.
Victorian doctors knew very well that circumcision denudes, desensitizes,
and disables the penis. Nevertheless, they were soon claiming that
circumcision cured epilepsy, convulsions, paralysis, elephantiasis,
tuberculosis, eczema, bed-wetting, hip-joint disease, fecal incontinence,
rectal prolapse, wet dreams, hernia, headaches, nervousness, hysteria,
poor eyesight, idiocy, mental retardation, and insanity.4

In fact, no procedure
in the history of medicine has been claimed to cure and prevent more
diseases than circumcision. As late as the 1970s, leading American
medical textbooks still advocated routine circumcision as a way to
prevent masturbation.5 The antisexual
motivations behind an operation that entails cutting off part of the
penis are obvious.

The radical practice of
routinely circumcising babies did not begin until the Cold War era.
This institutionalization of what amounted to compulsory circumcision
was part of the same movement that pathologized and medicalized birth
and actively discouraged breastfeeding. Private-sector, corporate-run
hospitals institutionalized routine circumcision without ever consulting
the American people. There was no public debate or referendum. It
was only in the 1970s that a series of lawsuits forced hospitals to
obtain parental consent to perform this contraindicated but highly
profitable surgery. Circumcisers responded by inventing new "medical"
reasons for circumcision in an attempt to scare parents into consenting.

Today the reasons given
for circumcision have been updated to play on contemporary fears and
anxieties; but one day they, too, will be considered irrational. Now
that such current excuses as the claim that this procedure prevents
cancer and sexually transmitted diseases have been thoroughly discredited,
circumcisers will undoubtedly invent new ones. But if circumcisers
were really motivated by purely medical considerations, the procedure
would have died out long ago, along with leeching, skull-drilling,
and castration. The fact that it has not suggests that the compulsion
to circumcise came first, the "reasons," later.

Millions of years
of evolution have fashioned the human body into a model of refinement,
elegance, and efficiency, with every part having a function and purpose.
Evolution has determined that mammals' genitals should be sheathed
in a protective, responsive, multipurpose foreskin. Every normal human
being is born with a foreskin. In females, it protects the glans of
the clitoris; in males, it protects the glans of the penis. Thus,
the foreskin is an essential part of human sexual anatomy.

Parents should enjoy
the arrival of a new child with as few worries as possible. The birth
of a son in the US, however, is often fraught with anxiety and confusion.
Most parents are pressured to hand their baby sons over to a stranger,
who, behind closed doors, straps babies down and cuts their foreskins
off. The billion-dollar-a-year circumcision industry has bombarded
Americans with confusing rhetoric and calculated scare tactics.

Information about
the foreskin itself is almost always missing from discussions about
circumcision. The mass circumcision campaigns of the past few decades
have resulted in pandemic ignorance about this remarkable structure
and its versatile role in human sexuality. Ignorance and false information
about the foreskin are the rule in American medical literature, education,
and practice. Most American medical textbooks depict the human penis,
without explanation, as circumcised, as if it were so by nature.

What Is the Foreskin?

The foreskin is a uniquely
specialized, sensitive, functional organ of touch. No other part of
the body serves the same purpose. As a modified extension of the penile
shaft skin, the foreskin covers and usually extends beyond the glans
before folding under itself and finding its circumferential point
of attachment just behind the corona (the rim of the glans). The foreskin
is, therefore, a double-layered organ. Its true length is twice the
length of its external fold and comprises as much as 80 percent or
more of the penile skin covering.6,7

The foreskin contains
a rich concentration of blood vessels and nerve endings. It is lined
with the peripenic muscle sheet, a smooth muscle layer with longitudinal
fibers. These muscle fibers are whirled, forming a kind of sphincter
that ensures optimum protection of the urinary tract from contaminants
of all kinds.

Like the undersurface
of the eyelids or the inside of the cheek, the undersurface of the
foreskin consists of mucous membrane. It is divided into two distinct
zones: the soft mucosa and the ridged mucosa. The soft mucosa lies
against the glans penis and contains ectopic sebaceous glands that
secrete emollients, lubricants, and protective antibodies. Similar
glands are found in the eyelids and mouth.

Adjacent to the soft
mucosa and just behind the lips of the foreskin is the ridged mucosa.
This exquisitely sensitive structure consists of tightly pleated concentric
bands, like the elastic bands at the top of a sock. These expandable
pleats allow the foreskin lips to open and roll back, exposing the
glans. The ridged mucosa gives the foreskin its characteristic taper.

On the underside of the
glans, the foreskin's point of attachment is advanced toward the meatus
(urethral opening) and forms a bandlike ligament called the frenulum.
It is identical to the frenulum that secures the tongue to the floor
of the mouth. The foreskin's frenulum holds it in place over the glans,
and, in conjunction with the smooth muscle fibers, helps return the
retracted foreskin to its usual forward position over the glans.

Retraction of the Foreskin

At birth, the foreskin
is usually attached to the glans, very much as a fingernail is attached
to a finger. By puberty, the penis will usually have completed its
development, and the foreskin will have separated from the glans.8
This separation occurs in its own time; there is no set age by which
the foreskin and glans must be separated. One wise doctor described
the process thus, "The foreskin therefore can be likened to a rosebud
which remains closed and muzzled. Like a rosebud, it will only blossom
when the time is right. No one opens a rosebud to make it blossom."9

Even if the glans and
foreskin separate naturally in infancy, the foreskin lips can normally
dilate only enough to allow the passage of urine. This ideal feature
protects the glans from premature exposure to the external environment.

The penis develops naturally
throughout childhood. Eventually, the child will, on his own, make
the wondrous discovery that his foreskin will retract. There is no
reason for parents, physicians, or other caregivers to manipulate
a child's penis. The only person to retract a child's foreskin should
be the child himself, when he has discovered that his foreskin is
ready to retract.

Parents should be wary
of anyone who tries to retract their child's foreskin, and especially
wary of anyone who wants to cut it off. Human foreskins are in great
demand for any number of commercial enterprises, and the marketing
of purloined baby foreskins is a multimillion-dollar-a-year industry.
Pharmaceutical and cosmetic companies use human foreskins as research
material. Corporations such as Advanced Tissue Sciences, Organogenesis,
and BioSurface Technology use human foreskins as the raw materials
for a type of breathable bandage.10

What Are the Foreskin's Functions?

The foreskin has numerous
protective, sensory, and sexual functions.

Protection: Just as the eyelids protect the eyes, the
foreskin protects the glans and keeps its surface soft, moist, and
sensitive. It also maintains optimal warmth, pH balance, and cleanliness.
The glans itself contains no sebaceous glands-glands that produce
the sebum, or oil, that moisturizes our skin.11 The foreskin produces
the sebum that maintains proper health of the surface of the glans.

Immunological Defense: The mucous membranes that line
all body orifices are the body's first line of immunological defense.
Glands in the foreskin produce antibacterial and antiviral proteins
such as lysozyme.12 Lysozyme is
also found in tears and mother's milk. Specialized epithelial Langerhans
cells, an immune system component, abound in the foreskin's outer
surface.13 Plasma cells in the
foreskin's mucosal lining secrete immunoglobulins, antibodies that
defend against infection.14

Erogenous Sensitivity: The foreskin is as sensitive as
the fingertips or the lips of the mouth. It contains a richer variety
and greater concentration of specialized nerve receptors than any
other part of the penis.15 These
specialized nerve endings can discern motion, subtle changes in
temperature, and fine gradations of texture.16,
17, 18, 19, 20, 21, 22, 23

Coverage During Erection: As it becomes erect, the penile
shaft becomes thicker and longer. The double-layered foreskin provides
the skin necessary to accommodate the expanded organ and to allow
the penile skin to glide freely, smoothly, and pleasurably over
the shaft and glans.

Self-Stimulating Sexual Functions: The foreskin's double-layered
sheath enables the penile shaft skin to glide back and forth over
the penile shaft. The foreskin can normally be slipped all the way,
or almost all the way, back to the base of the penis, and also slipped
forward beyond the glans. This wide range of motion is the mechanism
by which the penis and the orgasmic triggers in the foreskin, frenulum,
and glans are stimulated.

Sexual Functions in Intercourse: One of the foreskin's
functions is to facilitate smooth, gentle movement between the mucosal
surfaces of the two partners during intercourse. The foreskin enables
the penis to slip in and out of the vagina nonabrasively inside
its own slick sheath of self-lubricating, movable skin. The female
is thus stimulated by moving pressure rather than by friction only,
as when the male's foreskin is missing.

The foreskin fosters intimacy between the two partners by
enveloping the glans and maintaining it as an internal organ. The
sexual experience is enhanced when the foreskin slips back to allow
the male's internal organ, the glans, to meet the female's internal
organ, the cervix-a moment of supreme intimacy and beauty.

The foreskin may have functions
not yet recognized or understood. Scientists in Europe recently detected
estrogen receptors in its basal epidermal cells.24
Researchers at the University of Manchester found that the human foreskin
has apocrine glands.25 These specialized
glands produce pheromones, nature's chemical messengers. Further studies
are needed to fully understand these features of the foreskin and
the role they play.

Care of the Foreskin

The natural penis requires
no special care. A child's foreskin, like his eyelids, is self-cleansing.
For the same reason it is inadvisable to lift the eyelids and wash
the eyeballs, it is inadvisable to retract a child's foreskin and
wash the glans. Immersion in plain water during the bath is all that
is needed to keep the intact penis clean.26

The white emollient under
the child's foreskin is called smegma. Smegma is probably the most
misunderstood, most unjustifiably maligned substance in nature. Smegma
is clean, not dirty, and is beneficial and necessary. It moisturizes
the glans and keeps it smooth, soft, and supple. Its antibacterial
and antiviral properties keep the penis clean and healthy. All mammals
produce smegma. Thomas J. Ritter, MD, underscored its importance when
he commented, "The animal kingdom would probably cease to exist without
smegma."27

Studies suggest that
it is best not to use soap on the glans or foreskin's inner fold.28
Forcibly retracting and washing a baby's foreskin destroys the beneficial
bacterial flora that protect the penis from harmful germs and can
lead to irritation and infection. The best way to care for a child's
intact penis is to leave it alone. After puberty, males can gently
rinse their glans and foreskin with warm water, according to their
own self-determined needs.

How Common Is Circumcision?

Circumcision is almost
unheard of in Europe, South America, and non-Muslim Asia. In fact,
only 10 to 15 percent of men throughout the world are circumcised,
the vast majority of whom are Muslim.29 The neonatal circumcision
rate in the western US has now fallen to 34.2 percent.30 This relatively
diminished rate may surprise American men born during the era when
nearly 90 percent of baby boys were circumcised automatically, with
or without their parents' consent.

How Does Circumcision Harm?

The "medical" debate
about the "potential health benefits" of circumcision rarely addresses
its real effects.

Circumcision denudes: Depending on the amount of skin
cut off, circumcision robs a male of as much as 80 percent or more
of his penile skin. Depending on the foreskin's length, cutting
it off makes the penis as much as 25 percent or more shorter. Careful
anatomical investigations have shown that circumcision cuts off
more than 3 feet of veins, arteries, and capillaries, 240 feet of
nerves, and more than 20,000 nerve endings.31
The foreskin's muscles, glands, mucous membrane, and epithelial
tissue are destroyed, as well.

Circumcision desensitizes: Circumcision desensitizes the
penis radically. Foreskin amputation means severing the rich nerve
network and all the nerve receptors in the foreskin itself. Circumcision
almost always damages or destroys the frenulum. The loss of the
protective foreskin desensitizes the glans. Because the membrane
covering the permanently externalized glans is now subjected to
constant abrasion and irritation, it keratinizes, becoming dry and
tough. The nerve endings in the glans, which in the intact penis
are just beneath the surface of the mucous membrane, are now buried
by successive layers of keratinization. The denuded glans takes
on a dull, grayish, sclerotic appearance.

Circumcision disables: The amputation of so much penile
skin permanently immobilizes whatever skin remains, preventing it
from gliding freely over the shaft and glans. This loss of mobility
destroys the mechanism by which the glans is normally stimulated.
When the circumcised penis becomes erect, the immobilized remaining
skin is stretched, sometimes so tightly that not enough skin is
left to cover the erect shaft. Hair-bearing skin from the groin
and scrotum is often pulled onto the shaft, where hair is not normally
found. The surgically externalized mucous membrane of the glans
has no sebaceous glands. Without the protection and emollients of
the foreskin, it dries out, making it susceptible to cracking and
bleeding.

Circumcision disfigures: Circumcision alters the appearance
of the penis drastically. It permanently externalizes the glans,
normally an internal organ. Circumcision leaves a large circumferential
surgical scar on the penile shaft. Because circumcision usually
necessitates tearing the foreskin from the glans, pieces of the
glans may be torn off, too, leaving it pitted and scarred. Shreds
of foreskin may adhere to the raw glans, forming tags and bridges
of dangling, displaced skin.32

Depending on the amount of skin
cut off and how the scar forms, the circumcised penis may be permanently
twisted, or curve or bow during erection.33
The contraction of the scar tissue may pull the shaft into the abdomen,
in effect shortening the penis or burying it completely.34

Circumcision disrupts circulation: Circumcision interrupts
the normal circulation of blood throughout the penile skin system
and glans. The blood flowing into major penile arteries is obstructed
by the line of scar tissue at the point of incision, creating backflow
instead of feeding the branches and capillary networks beyond the
scar. Deprived of blood, the meatus may contract and scarify, obstructing
the flow of urine.35 This condition,
known as meatal stenosis, often requires corrective surgery. Meatal
stenosis is found almost exclusively among boys who have been circumcised.

Circumcision also severs the
lymph vessels, interrupting the circulation of lymph and sometimes
causing lymphedema, a painful, disfiguring condition in which the
remaining skin of the penis swells with trapped lymph fluid.

Circumcision harms the developing brain: Recent studies
published in leading medical journals have reported that circumcision
has long-lasting detrimental effects on the developing brain,36
adversely altering the brain's perception centers. Circumcised boys
have a lower pain threshold than girls or intact boys.37
Developmental neuropsychologist Dr. James Prescott suggests that
circumcision can cause deeper and more disturbing levels of neurological
damage, as well. 38, 39

Circumcision is unhygienic and unhealthy: One of the most
common myths about circumcision is that it makes the penis cleaner
and easier to take care of. This is not true. Eyes without eyelids
would not be cleaner; neither would a penis without its foreskin.
The artificially externalized glans and meatus of the circumcised
penis are constantly exposed to abrasion and dirt, making the circumcised
penis, in fact, more unclean. The loss of the protective foreskin
leaves the urinary tract vulnerable to invasion by bacterial and
viral pathogens.

The circumcision wound is larger
than most people imagine. It is not just the circular point of union
between the outer and inner layers of the remaining skin. Before a
baby is circumcised, his foreskin must be torn from his glans, literally
skinning it alive. This creates a large open area of raw, bleeding
flesh, covered at best with a layer of undeveloped proto-mucosa. Germs
can easily enter the damaged tissue and bloodstream through the raw
glans and, even more easily, through the incision itself.

Even after the wound
has healed, the externalized glans and meatus are still forced into
constant unnatural contact with urine, feces, chemically treated
diapers, and other contaminants.

Female partners of
circumcised men do not report a lower rate of cervical cancer,40
nor does circumcision prevent penile cancer.41
A recent study shows that the penile cancer rate is higher in the
US than in Denmark, where circumcision, except among Middle-Eastern
immigrant workers, is almost unheard of.42
Indeed, researchers should investigate the possibility that circumcision
has actually increased the rate of these diseases.

Circumcision does not
prevent acquisition or transmission of sexually transmitted diseases
(STDs). In fact, the US has both the highest percentage of sexually
active circumcised males in the Western world and the highest rates
of sexually transmitted diseases, including AIDS. Rigorously controlled
prospective studies show that circumcised American men are at a
greater risk for bacterial and viral STDs, especially gonorrhea,43
nongonoccal urethritis,44 human
papilloma virus,45 herpes simplex
virus type 2,46 and chlamydia.47

Circumcision is always risky: Circumcision always carries
the risk of serious, even tragic, consequences. Its surgical complication
rate is one in 500.48 These complications
include uncontrollable bleeding and fatal infections.49
There are many published case reports of gangrene following circumcision.50
Pathogenic bacteria such as staphylococcus, Proteus, Pseudomonas,
other coliforms, and even tuberculosis can cause infections leading
to death.51, 52 These organisms
enter the wound because it provides easy entry, not because the
child is predisposed to infection.

Medical journals have published
numerous accounts of babies who have had part or all of their glans
cut off while they were being circumcised.53,54,55
Other fully conscious, unanesthetized babies have had their entire
penis burned off with an electrocautery gun.56,57,
58 The September 1989 Journal of Urology published
an account of four such cases.59 The article described the
sex-change operation as "feminizing genitoplasty," performed on these
babies in an attempt to change them into girls. The March 1997 Archives
of Pediatrics and Adolescent Medicine described one young
person's horror on learning that "she" had been born a normal male,
but that a circumciser had burned his penis off when he was a baby.60
Many other similar cases have been documented.61,62
Infant circumcision has a reported death rate of one in 500,000.63,64

Circumcision harms mothers: Scientific studies have consistently
shown that circumcision disrupts a child's behavioral development.
Studies performed at the University of Colorado School of Medicine
showed that circumcision is followed by prolonged, unrestful non-REM
(rapid-eye-movement) sleep.65 In
response to the lengthy bombardment of their neural pathways with
unbearable pain, the circumcised babies withdrew into a kind of
semicoma that lasted days or even weeks.

Numerous other studies have
proven that circumcision disrupts the mother-infant bond during the
crucial period after birth. Research has also shown that circumcision
disrupts feeding patterns. In a study at the Washington University
School of Medicine, most babies would not nurse right after they were
circumcised, and those who did would not look into their mothers'
eyes.66

Circumcision violates patients' and human rights: No one
has the right to cut off any part of someone else's genitals without
that person's competent, fully informed consent. Since it is the
infant who must bear the consequences, circumcision violates his
legal rights both to refuse treatment and to seek alternative treatment.
In 1995, the American Academy of Pediatrics Committee on Bioethics
stated that only a competent patient can give patient consent or
informed consent.67 An infant is
obviously too young to consent to anything. He must be protected
from anyone who would take advantage of his defenselessness. The
concept of informed parental permission allows for medical interventions
in situations of clear and immediate medical necessity only, such
as disease, trauma, or deformity. The human penis in its normal,
uncircumcised state satisfies none of these requirements.

Physicians have a duty to refuse
to perform circumcision. They also must educate parents who, out of
ignorance or misguidance, request this surgery for their sons. The
healthcare professional's obligation is to protect the interests of
the child. It is unethical in the extreme to force upon a child an
amputation he almost certainly would never have chosen for himself.

Common Sense

To be intact, as nature
intended, is best. The vast majority of males who are given the choice
value their wholeness and keep their foreskins, for the same reason
they keep their other organs of perception. Parents in Europe and
non-Muslim Asia never have forced their boys to be circumcised. It
would no more occur to them to cut off part of their boys' penises
than it would to cut off part of their ears. Respecting a child's
right to keep his genitals intact is normal and natural. It is conservative
in the best sense of the word.

A circumcised father
who has mixed feelings about his intact newborn son may require gentle,
compassionate psychological counseling to help him come to terms with
his loss and to overcome his anxieties about normal male genitalia.
In such cases, the mother should steadfastly protect her child, inviting
her husband to share this protective role and helping him diffuse
his negative feelings. Most parents want what is best for their baby.
Wise parents listen to their hearts and trust their instinct to protect
their baby from harm. The experience of the ages has shown that babies
thrive best in a trusting atmosphere of love, gentleness, respect,
acceptance, nurturing, and intimacy. Cutting off a baby's foreskin
shatters this trust. Circumcision wounds and harms the baby and the
person the baby will become. Parents who respect their son's wholeness
are bequeathing to him his birthright-his body, perfect and beautiful
in its entirety.